Triangle tilt and humeral surgery:Meta-analysis of efficacy and functional outcome

AIM: To systematically review and analyze the overall impact and effectiveness of bony surgical procedures, the triangle tilt and humeral surgery in a comparative manner in permanent obstetric brachial plexus injury(OBPI) patients.METHODS: We conducted a literature search and identified original full research articles of OBPI patients treated with a secondary bony surgery, particularly addressing the limitation of shoulder abduction and functions. Further, we analyzed and compared the efficacy and the surgical outcomes of 9 humeral surgerypapers with 179 patients, and 4 of our secondary bony procedure, the triangle tilt surgical papers with 86 patients. RESULTS: Seven hundred and thirty-one articles were identified, using the search term "brachial plexus" and obstetric or pediatric(246 articles) or neonatal(219 articles) or congenital(188 articles) or "birth palsy"(121 articles). Further, only a few articles were identified using the bony surgery search, osteotomy "brachial plexus" obstetric(35), "humeral osteotomy" and "brachial plexus"(17), and triangle tilt "brachial plexus"(14). Of all, 12 studies reporting pre- and postoperative or improvement in total Mallet functional score were included in this study. Among these, 9 studies reported the humeral surgery and 4 were triangle tilt surgery. We used modified total Mallet functional score in this analysis. Various studies with humeral surgery showed improvement of 1.4, 2.3, 5.0 and 5.6 total Mallet score, whereas the triangle tilt surgery showed improvement of 5.0, 5.5, 6.0 and 6.2.CONCLUSION: The triangle tilt surgery improves on what was achieved by humeral osteotomy in the management of shoulder function in OBPI patients.

Improvements after mod Quad and triangle tilt revision surgical procedures in obstetric brachial plexus palsy

AIM To compare outcomes of our revision surgical operations in obstetric brachial plexus palsy(OBPP) patients to results of conventional operative procedures at other institutions. METHODS We analyzed our OBPP data and identified 10 female and 10 male children aged 2.0 to 11.8 years(average age 6.5 years), who had prior conventional surgical therapies at other clinics. Of the 20 patients, 18 undergone triangle tilt, 2 had only mod Quad. Among 18 patients, 8 had only triangle tilt and 10 had also mod Quad as revision surgeries with us. We analyzed the anatomical improvements and functional modified Mallet statistically before and after a year post-revision operations.RESULTS Pre-revision surgery average modified Mallet score was 12.0 ± 1.5. This functional score was greatly improved to 18 ± 2.3(P < 0.0001) at least one-year after revision surgical procedures. Radiological scores(PHHA and glenoid version) were also improved significantly to 31.9 ± 13.6(P < 0.001),-16.3 ± 11(P < 0.0002), at least one-year after triangle tilt procedure. Their mean pretriangle tilt(yet after other surgeon's surgeries) PHHA, glenoid version and SHEAR were 14.6 ± 21.7,-31.6 ± 19.3 and 16.1 ± 14.7 respectively.CONCLUSION We demonstrate here, mod Quad and triangle tilt assuccessful revision surgical procedures in 20 OBPP patients, who had other surgical treatments at other clinics before presenting to us for further treatment.

Comparing the Surgical Outcomes of Modified Quad and Triangle Tilt Surgeries to other Procedures Performed in Obstetric Brachial Plexus Injury

Purpose: To compare results from our surgical treatment experiences in children with obstetric brachial plexus injuries (OBPI), to those who have had other surgical treatments. Methods: We conducted a retrospective study in our medical records consisting of two groups of OBPI patients. Group 1: 26 OBPI children (16 girls and 10 boys), age range between 2.0 and 12.0 (mean age 6.9), who have undergone surgical treatments at other institutions between 2005 and 2010. Group 2: 45 OBPI children (20 boys and 25 girls), age between 0.7 and 12.9 (mean age 3.7), who have had modified Quad and triangle tilt surgical treatment between 2005 and 2010 at our institution. In both groups Mean modified Mallet scores and radiological scores were measured and compared. All measurements were made at least one year post surgery in both groups. Results: Post-operative mean modified Mallet score was 11.8 ± 2.4 in group 1 patients, whereas post-mean modified Mallet score was 20 ± 2.7 (P 0.0001) following modified Quad and triangle tilt surgeries in group 2 patients. Further, their radiological scores such as posterior subluxation, and glenoid version were 13.4 ± 21.3 and ﹣30.2 ± 19.1 in group 1, whereas 32.1 ±13.5 (P 0.0004), and ﹣16.3 ± 11.5 (P 0.008) in group 2 patients, when compared to normal values of 50, and 0 respectively. Conclusion: Patients who have had mod Quad and triangle tilt for OBPI obtained significantly better functional outcomes in modified total Mallet score as well as in radiological scores, when compared to those OBPI children, who underwent other procedures such as posterior glenohumeral capsulorrhaphy, biceps tendon lengthening, humeral osteotomy, anterior capsule release, nerve transfer/graft, botox and muscle/tendon transfer and release.

Finger movement at birth in brachial plexus birth palsy

AIM: To investigate whether the finger movement at birth is a better predictor of the brachial plexus birth injury.METHODS: We conducted a retrospective study reviewing pre-surgical records of 87 patients with residual obstetric brachial plexus palsy in study 1. Posterior subluxation of the humeral head(PHHA), and glenoid retroversion were measured from computed tomography or Magnetic resonance imaging, and correlated with the finger movement at birth. The study 2 consisted of 141 obstetric brachial plexus injury patients, who underwent primary surgeries and/or secondary surgery at the Texas Nerve and Paralysis Institute. Information regarding finger movement was obtained from the patient's parent or guardian during the initial evaluation.RESULTS: Among 87 patients, 9(10.3%) patients who lacked finger movement at birth had a PHHA > 40%, and glenoid retroversion <-12°, whereas only 1 patient(1.1%) with finger movement had a PHHA > 40%, and retroversion <-8° in study 1. The improvement in glenohumeral deformity(PHHA, 31.8% ± 14.3%; andglenoid retroversion 22.0°± 15.0°) was significantly higher in patients, who have not had any primary surgeries and had finger movement at birth(group 1), when compared to those patients, who had primary surgeries(nerve and muscle surgeries), and lacked finger movement at birth(group 2),(PHHA 10.7% ± 15.8%; Version-8.0°± 8.4°, P = 0.005 and P = 0.030, respectively) in study 2. No finger movement at birth was observed in 55% of the patients in this study group.CONCLUSION: Posterior subluxation and glenoid retroversion measurements indicated significantly severe shoulder deformities in children with finger movement at birth, in comparison with those lacked finger movement. However, the improvement after triangle tilt surgery was higher in patients who had finger movement at birth.